The Patient Protection & Affordable Care Act: Next Steps in Maine. February 8,

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1 The Patient Protection & Affordable Care Act: Next Steps in Maine February 8,

2 Maine Medical Association Voluntary membership association of over 3,600 Maine physicians, residents, and medical students Formed in 1853 Mission: to support Maine physicians, advance the quality of medicine in Maine, and promote the health of all Maine citizens 2

3 MMA Efforts MeHAF Grant, Informing, Engaging, and Educating Maine People about Health Reform MeHAF Grant, Informing Health Reform Administrative Procedures Looking for practices interested in partnering Distributing materials to patients Informing regulatory comments Access to more resources/materials 3

4 Goals of the ACA Expand health insurance coverage Improve coverage for those with health insurance Improve quality of care Control rising health care costs 4

5 Supreme Court Decision Court has jurisdiction to decide case Mandate is a constitutional exercise of Congress power to tax Medicaid expansion violates Congress spending clause power as unconstitutionally coercive Remedy is to limit HHS Secretary s power to withhold existing federal Medicaid funds for state non-compliance 5

6 Expanding Coverage Most sweeping health care legislation since establishment of Medicare in 1965 Possibility of expanding health insurance coverage to 31 million more Americans by 2019 Mix of expanded private coverage through exchange, increased Medicaid eligibility (now optional ), maintenance of employerbased coverage 6

7 Expanding Coverage by 2019: 133,400 newly covered in ME (w. Medicaid expansion) 7

8 2008 MMA Survey When considering the topic of health care reform, would you prefer: To make improvements to the current public/private system (47.7% of all respondents) A single-payer system such as a Medicare for all approach (52.3%) 8

9 Expanding Coverage (in place since 2010) Adult children can remain on their parents health insurance policy until age 26 Establishment of temporary insurance plan for adults with pre-existing conditions who are currently uninsured Small business tax credits available to employers with 25 or fewer employees with average wages below $50,000 9

10 Expanding Coverage: 2014 Health insurance exchanges for individuals and small business begin in every state Centralized on-line marketplace for private insurance Web portal and telephone hotline Enrollment must begin October 1, 2013 Can be federally-run, state-run or partnership model Premium tax credit and cost-sharing subsidies provided to individuals from % of FPL See Subsidy Calculator at: healthreform.kff.org/subsidycalculator.aspx Current challenge: tax subsidies in federal exchange? 10

11 An Exchange in Maine Expanding Coverage: 2014 Maine will default to federally-facilitated exchange Deadline for state to declare intent for statebased exchange was 12/14/12 & for partnership model (plan management and/or consumer assistance functions) was until 2/15/13 11

12 Expanding Coverage: 2014 Health Plans in the Exchange Must include all essential health benefits Being defined by regulations; in Maine = state s most popular small group plan (Anthem PPO) Must include 10 mandatory categories (i.e. ambulatory, emergency, maternity, prescription drug, mental health) Meet requirements for out of pocket and deductible limits Offer all metal levels of coverage (benefits with actuarial levels of 60%, 70%, 80%, 90%) 12

13 Medicaid expansion Expanding Coverage: 2014 Eligibility can be provided to all Americans up to 133% of FPL at 100% fed match No longer limited to those categorically eligible (e.g. pregnant women, those with children or disabilities) Estimated 69,000 individuals in Maine If no expansion, those earning less than 100% FPL are NOT eligible for Exchange subsidies, but those % could participate in Exchange 13

14 Expanding Coverage: 2014 Medicaid expansion: Will Maine Participate States no longer can be penalized by losing ALL Medicaid funds for not participating Lost money for the state: Newly eligible reimbursed at 100% for first three years, then 95% and finally 90% ( vs approx 63%) Disproportionate Share Payments reduced in ACA pressure from providers CMS clarified that states cannot do partial expansion (e.g. up to 100% FPL) 14

15 Expanding Coverage: 2014 Medicaid: Maintenance of Effort Requirement ACA requires states to maintain current eligibility until 2014 Legislature approved budget that cut parents from % FPL, parents from % FPL, young adults 19-20, Medicare Savings Program CMS approved parents from % FPL and Medicare Savings Program but not other groups protected by MOE 15

16 Expanding Coverage: Individual Mandate Individuals will be required to have health coverage that meets minimum standards Individual mandate spreads costs among whole population Mandate enforced through the tax system & now is considered a tax by the Supreme Court Penalty for not having insurance: greater of $695 (up to $2085 for family) or 2.5% of family income when fully phased in in 2016 ($95 in 2014) Exemptions for certain groups and if people cannot find affordable health insurance 16

17 Expanding Coverage: Employer Requirements Employers with 51+ FTE employees not offering affordable coverage will face penalties of up to $2000 per full-time worker per year Small employers with up to 50 employees will be exempt from penalties Tax credits available for some small business that offer health benefits 17

18 Some Uninsured Will Remain Congressional Budget Office (CBO) estimates 26 million uninsured in 2019 assuming Medicaid expansion Who are they? Immigrants who are not legal residents Eligible for Medicaid but not enrolled Exempt from the mandate (most because can t find affordable coverage) Choose to pay penalty in lieu of getting coverage Many remaining uninsured will be low-income 18

19 Improving Coverage Consumer protections and administrative simplification in health insurance industry Medical loss ratio (2012) 85% small group/80% individual (ME has waiver to 65%) Essential Health Benefits Package (2014) To ensure minimum coverage standards for most health plans sold in or out of the exchange Dec 2011 HHS Guidance: package based on benchmark plan selected by state (by Q3 2012) or defaults Maine defaulted to largest small group (Anthem plan) rulemaking being finalized Strengthened appeals process Uniform benefits information 19

20 Improving Coverage Consumer Operated and Oriented Plans (CO-OPs) CMS awarded $62.1 million in financing for Maine Community Health Options (MCHO), a Maine-based COOP A new type of non-profit health insurer Governed by its subscribers Designed to be operational in 2014 and offered via the exchange 20

21 Improving Coverage Prevents denials based on pre-existing conditions Prohibition on denial of coverage or benefits (children 2010, adults 2014) Elimination of lifetime benefit caps (2010) and annual limits (phase out by 2014) 21

22 Improving Coverage Expands & improves coverage of preventive services No cost initial Welcome to Medicare Preventive Visit and yearly Wellness Visit for those with Medicare Part B No cost-sharing for proven preventive services for Medicare, Medicaid and private insurance (e.g. cancer & diabetes screenings, vaccinations) Grants for small employer wellness programs 22

23 Improving Coverage Improves Medicare prescription drug benefits by reducing the donut hole In 2011, ~12,000 people in ME had received a discount with an average savings of $530 per beneficiary for a total savings of $6,306,962 Enhanced federal funding for home & community based services but implementation of CLASS Act long term care insurance suspended 23

24 Improving Quality Develops a national quality strategy Promotes comparative effectiveness research to identify most effective treatments and interventions Creates enhanced data collection to address health care disparities Requires public reporting of physician performance data and gifts received from the pharmaceutical industry 24

25 Improving Quality Develops new models for coordinating and delivering care Medicaid Health Homes Medicare ACOs (4 now approved in Maine) Payment reform to promote quality Medicare quality reporting incentive payments Demonstration projects for bundled payments for episodes of care Medicare Value-Based Purchasing program Decreased Medicare payments for readmissions 25

26 Improving Quality: Primary and Preventive Care Increases Medicare and Medicaid PCP payments Primary care/general surgery Medicare bonus payments of approx 10% through 2016 Medicaid payments to 100% of Medicare rates for primary care services provided by primary care physicians & advanced practice professionals practicing under their direct supervision in Incentives to practice primary care (e.g. loan forgiveness, residency slots, payment bonuses) No cost-sharing for certain preventive services Funds population-based prevention activities (but $5 billion cut to Prevention Fund for temp SGR fix) 26

27 Containing Health Care Costs Creates greater oversight of health insurance premiums and insurer practices Increases competition and price transparency through Exchanges Reforms Medicare payments Tests new, more efficient delivery system models in Medicare and Medicaid Emphasis on prevention & primary care Independent Payment Advisory Board Legal challenge: did Congress abrogate resp. 27

28 Useful ACA Web Sites National Federal government: AMA: Kaiser Family Foundation: InsureUStoday: Maine Legislative branch: 28

29 Where to refer patients Consumers for Affordable Health Care (TTY) Mainecahc.org Local Area Agency on Aging (for Medicare members)

30 Questions? Maine Medical Association Jessa Barnard, Esq Associate General Counsel x 211 https://www.mainemed.com/education-infocme/health-system-reform 30

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